CHIME Fall CIO Forum Scholarship Application

Candidate's Name*

( Must be a CHIME member)

First Last

Job Title*

Organization*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

What is the size of your organization?

Which of the following best describes your healthcare organization’s tax status?

Not-for-Profit
For-Profit
Government

What is your facility's annual gross revenue?

Note: If your facility is part of larger healthcare organization, please respond based on your individual facility’s gross revenue.

I would qualify for scholarships aimed at the following populations:

(Please check all that apply) (Be sure to check if you're eligible for the Women and Minority Scholarship found on CHIME's scholarship page as well)

Minorities
Women
Military
Critical Access Hospital

In addition to the CHIME Education Foundation Scholarships, the Neal L. Patterson Community and Rural Hospital Scholarship, funded by Cerner, is a full registration scholarship available to current CHIME members who are employees of a community or rural hospital or health system.

I am an employee of a community or rural hospital or health system:*

Yes
No

How long have you been a CHIME member?

When was the last time you attended the Fall CIO Forum?

Have you applied for a CHIME scholarship before?

Yes
No

Which scholarship and when?

Have you received a CHIME scholarship before?

Yes
No

Which scholarship and when?

What activities/committees have you been involved in with CHIME

Please describe any financial hardship that affects the reasoning for this scholarship.

Are there any available funds for this type of training at your facility? If so, were you denied funding and would a partial scholarship assist you in being able to attend the program

I will require additional time to arrange for a VISA to attend the CHIME CIO Fall Forum, or have other travel or logistical arrangements that may affect my ability to utilize the scholarship if awarded.

No
Yes

If yes, please explain

I commit that I have arranged funding for, or will be able to cover, all additional travel expenses not covered by this Full Registration Scholarship necessary to utilize the scholarship if awarded.

Yes
No

If no, please explain and/or note additional financial needs::

Upload Supporting Documents

1. Upload Essay*

Please use .pdf

2. Upload Current Resume*

Please use .pdf

* CHIME may request to share/publish the submitted essay for educational/marketing purposes. No information shall be shared without the express written consent of the scholarship applicant.

Neal L. Patterson Community and Rural Hospital Scholarship

APPLICATION CRITERIA

Qualifications

Materials Required

Application deadline September 6, 2020.

Upload Supporting Documents